Delirium and Deep Sedation in a Long-Term Acute Care Hospital

Abstract

Research conducted in the intensive care unit (ICU) suggests the development of delirium, agitation, and deep-sedation effects numerous patient outcomes. There is little information, however, about the frequency of these syndromes/symptoms in the Long Term Acute Care Hospital (LTACH) setting (i.e., centers that specialize in mechanical ventilation weaning and rehabilitation). This interim analysis will describe the prevalence, incidence, and duration of delirium, coma, deep sedation, and agitation in adults who require mechanical ventilation in the LTACH setting and explore the accuracy of Registered Nurses’ (RNs) assessment of delirium. The ongoing study utilizes a prospective, observational, before/after design. The first five patients enrolled at a single-center LTACH were included. A trained research assistant performed daily, in-person delirium and level of arousal assessments using valid and reliable tools (i.e., the Confusion Assessment Method -ICU [CAM-ICU] and Richmond Agitation Sedation Scale [RASS] respectively) for up to 28 days, discharge, and/or death. Medical charts were used to record RNs’ delirium assessments. In-person assessments were performed on 62/100 (62%) total LTACH days. From the total days assessed (n=62), 39 days (63%) were spent at goal RASS (i.e., -1 to +1), 22 (35%) deeply sedated (i.e., -2, -3), 1 (2%) in coma (i.e., -4 or -5), and no days agitated (i.e., +2 to +4). Excluding the 1 coma day, delirium occurred on 28/61 (46%) of all days assessed. RNs frequently misinterpreted CAM-ICU results, with 55/100 (55%) episodes of CAM-ICU recorded as “Unable to Assess” in patients who had applicable RASS scores. Episodes of deep sedation and delirium are common in the LTACH setting, occurring in over 1/3 and nearly 1/2 of all days assessed respectively. Over half of RN CAM-ICU assessments were deemed inaccurate, creating an opportunity to improve LTACH RNs’ delirium assessment skills.